Healthcare Provider Details

I. General information

NPI: 1790146132
Provider Name (Legal Business Name): FAMILY MILLENNIUM DENTISTRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1342 W RANDOLPH ST
CHICAGO IL
60607-1522
US

IV. Provider business mailing address

1342 W RANDOLPH ST
CHICAGO IL
60607-1522
US

V. Phone/Fax

Practice location:
  • Phone: 312-767-0407
  • Fax: 312-988-0292
Mailing address:
  • Phone: 312-767-0407
  • Fax: 312-988-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number021001094
License Number StateIL

VIII. Authorized Official

Name: LAWRENCE H ZAGER
Title or Position: DENTIST / OWNER
Credential: D.D.S. PC
Phone: 312-767-0407